Form SSA-e2960-U3-CZ USA/CZ3 to request a Czech Republic certified coverage record if needed and to certify the filing date for Czech benefits, establish factors of entitlement, and U.S. benefit information.

A U.S. totalization earnings record.

Medical evidence from SSA’s files, if the Czech claim is for disability benefits.

CZ/USA 202 and any necessary proofs and any evidence

Letter to claimant advising them that their claim was forwarded to the Czech Republic Agency if claim is for Czech benefits only.